Uncommon multisystemic involvement in a case of Henoch-Sch?nlein purpura

Patients with critical chronic limb ischaemia may be addressed by different approaches: conservatively with control of risk factors and in some cases also medical treatment, or by amputation, primarily or secondarily, following attempt to revascularise, or treatment may be surgical, either with endovascular or open vascular surgery. The different options are shortly described, with indications and likely results which may be obtained in each case. The paper concludes that no matter what treatment is considered, control of risk factors is of benefit. Patients who, judged by the vascular surgeon, are operable, and who are physically active and without serious medical risk factors, are best treated with open surgical revascularisation. In high risk cases or when inoperable, medical therapy may be an option. Endovascular treatment may be considered in patients with high surgical risk. Primary amputation should be considered in cases where outcome of surgical treatment may be seriously affected by medical risk factors, in cases with progressive ischaemia, in cases where the chances of successful surgery are small or when the patient is in a situation where the benefit of surgery is negligible.     

Treatment of thromboangiitis obliterans (Buerger's disease) by intramuscular gene transfer of vascular endothelial growth factor: preliminary clinical results

PURPOSE: Thromboangiitis obliterans (TAO), or Buerger's disease, a distinct form of vascular occlusive disease that afflicts the peripheral arteries of young smokers, is often characterized by an inexorable downhill course even in patients who discontinue smoking once a stage of critical limb ischemia associated with ulceration or gangrene is reached. As part of a phase I clinical trial to document the safety and efficacy of intramuscular gene transfer of naked plasmid DNA-encoding vascular endothelial growth factor (phVEGF165) in the treatment of critical limb ischemia, we treated TAO in 6 patients. METHODS: Seven limbs in 6 patients (3 men, 3 women; mean age, 33 years; range, 33 to 51 years) who satisfied the criteria for TAO and had signs or symptoms of critical limb ischemia were treated twice, 4 weeks apart, with 2 or 4 mg of phVEGF165, which was administered by direct intramuscular injection at 4 arbitrarily selected sites in the ischemic limb. The gene expression was documented by enzyme-linked immunosorbent assay that was performed on peripheral blood samples. RESULTS: The ulcers that were nonhealing for more than 1 month healed completely in 3 of 5 limbs after the intramuscular phVEGF165 gene therapy. Nocturnal rest pain was relieved in the remaining 2 patients, although both continue to have claudication. The evidence of the improved perfusion to the distal ischemic limb included an increase of more than 0.1 in the ankle brachial index in 3 limbs, an improved flow shown with magnetic resonance imaging in 7 of the 7 limbs, and newly visible collateral vessels shown with serial contrast angiography in 7 of the 7 limbs. The adverse consequences of the phVEGF165 gene transfer were limited to transient ankle or calf edema in 3 of the 7 limbs. Two patients with advanced distal forefoot gangrene ultimately required below-knee amputation despite the evidence of improved perfusion. A histologic section disclosed the classic pathologic findings of TAO. CONCLUSION: Therapeutic angiogenesis with phVEGF165 gene transfer, if instituted before the development of forefoot gangrene, may provide a novel therapy for patients with advanced Buerger's disease that is unresponsive to standard medical or surgical treatment methods.     

Eprosartan does not affect the pharmacodynamics of warfarin

The purpose of this study was to conduct a retrospective analysis of the clinical spectrum, treatment and morbidity of the patients who have suffered high tension electrical injuries with current passage through their body (59 patients). Voltage, localization and surgical treatment seem to be the main factors influencing the lesion and the morbidity. The following points were considered: (1) Is there any relation between known factors such as voltage and the localization of the points of contact with the incidence and the type of complications and sequelae? (2) Do the observations show that wound management and the excision of dead tissues is the most adequate? From factors studied in our patients (voltage, point of entry and pathway of current, associated multiple trauma or flame burns, surgical treatment) we have found that the voltage does not have any influence on the severity of the wound nor on the percentage of sequelae (cataracts, limb amputation, neurologic complications). The current pathway, as well as its points of entry, does not show any relation with the presence of renal failure, cardiac arrhythmia and cataracts. A clear relationship between the point of entry of the current and the appearance of neurologic injury with presence of paralysis and permanent regional anaesthesia at the same level was observed. The presence of associated burns was not related to any other complications or sequelae. For those patients whose length of contact has been shorter we find a lower rate of amputations despite having associated limb fractures. Fasciotomy incisions appear to confer benefit as this series shows that this procedure decreases the rate of limb amputations.     

Hypokalemia after normal doses of neubulized albuterol (salbutamol)

PURPOSE: To evaluate the potential influence of intraoperative digital subtraction angiography (DSA) on surgical strategy after balloon thromboembolectomy for acute lower limb ischemia. METHODS: Thirty-six consecutive patients with critical limb ischemia were treated with balloon catheter thromboembolectomy assessed by intraoperative digital subtraction angiography. The need for further intervention was determined by the surgeon based on the DSA information. Primary completion DSAs were made in every procedure; subsequent completion DSAs were performed after reinterventions at the discretion of the surgeon. RESULTS: Initial treatment in this patient group consisted of 14 embolectomies and 26 thrombectomies. From the completion DSAs of these 40 procedures, a reintervention was judged necessary in 27 (68%). Of these 27 reinterventions, 17 underwent a secondary DSA; evidence supporting a third intervention was found in 11 (64%). Overall, a total of 69 DSAs were performed in these patients. Mortality was 22% (8 patients); 38% (5) in embolectomy patients and 13% (3) in the thrombectomy cohort. Eighty-eight percent of the embolectomy survivors had an uneventful recovery, while only 25% of the thrombectomy survivors experienced an uncomplicated follow-up. In one quarter of the surviving thrombectomy patients, a surgical revascularization resulted in limb salvage; in 45%, a major amputation was the outcome. CONCLUSIONS: In this study, the completeness of balloon catheter thromboembolectomy was assessed by intraoperative DSA. As a result, 68% of the procedures required one or more reinterventions for residual lesions. Intraoperative DSA is a simple and quick technique that may be a promising adjunct to intraoperative balloon thromboembolectomy.     

Ventilation during total intravenous anaesthesia with ketamine

In a retrospective study, we analyzed our experiences in 24 patients with acute ischemia from popliteal artery aneurysms over a period of 27 years and evaluated the value of a preoperative lytic therapy as an adjunct to surgical revascularization, compared to surgery alone. Preoperative urokinase therapy revealed a satisfactory improvement of the runoff in all cases. Follow-up angiography showed complete lysis in 6 and incomplete lysis in 3 of 9 patients. In contrast, in patients treated by surgery alone, postoperative angiography showed residual clots in all cases. The overall amputation rate was 25% (6/24) in 24 popliteal aneurysms with acute ischemia, including four patients with primary amputation for irreversible gangrene. Bypass grafting alone resulted in an early amputation rate of 9% (1/11) and occlusive complications of 45% (5/11) compared to no limb loss and no bypass complication in patients who underwent combined surgery and preoperative lysis (0/9). Our results underline the value of preoperative lytic therapy as an important factor in the management of acute ischemia in popliteal artery aneurysms.     

The attitudes of patients and health care personnel to rectal drug administration following day case surgery

BACKGROUND: Arterial "steal" is a well-known complication following proximal arteriovenous (AV) fistula, but its manifestations comprise a wide spectrum of symptoms and there are no clear indications for those patients who need surgical repair. STUDY DESIGN: Among 180 consecutive AV fistulas of various configurations, with the brachial artery as the donor artery in all patients, 111 patients were studied retrospectively (group A) and 69 patients were studied prospectively (group B). Patient records were reviewed in group A, and the decision for surgical correction of limb-threatening steal was based on clinical grounds only. In group B, all patients were followed prospectively; postoperative systolic blood pressure measurements were obtained, and a systolic pressure index (SPI) was calculated (postoperative forearm systolic pressure divided by contralateral forearm systolic pressure). In patients with an SPI < 0.6, nerve conduction studies (NCS) were performed. The decision for operation in this group was based on clinical examination, SPI, and NCS. RESULTS: Seven patients were operated on for steal-induced limb-threatening ischemia; in all seven patients, ischemia developed immediately after access construction. One additional patient with mild symptoms and deterioration in repeated NCS was considered a candidate for ischemic monomelic neuropathy and was successfully operated on 1 month later. The ligation-bypass technique was used in all patients, consisting of arterial ligature distal to the takeoff of the graft and short arterial bypass from a point proximal to the inflow of the access to a point just distal to ligation. In 94% of the patients, some degree of distal ischemia was detected (SPI < 0.8); patients with SPI < 0.5 were most likely to have impaired NCS. CONCLUSIONS: Steal-induced limb-threatening ischemia necessitating immediate surgical repair occurred in 3.9% (7 of 180) of our patients. The decision for surgical correction of steal should be based on clinical examination. Nerve conduction studies may be useful in patients who have an SPI value < 0.5 to detect candidates who might develop ischemic monomelic neuropathy. In similar patients, surgical treatment of steal should be offered.     

Lower limb ischaemia in the octogenarian: is limb salvage surgery worthwhile?

Vascular surgeons are being asked to manage vascular disease in an increasingly elderly population, and advanced age may be considered a relative contraindication to limb salvage surgery with an amputation seeming the preferred option. We present a review of 50 patients over the age of 80 years, presenting with ischaemic rest pain, ulceration or gangrene of the lower extremity. Six patients were treated conservatively, four of whom died during the same admission. Only two patients proved suitable for transluminal angioplasty as the sole curative procedure. Twelve patients (24%) underwent primary amputation with a perioperative mortality of 3/12 (25%). Five patients (10%) had an iliac bypass procedure, and 25 patients (50%) were considered suitable for infrainguinal bypass. Of the latter group 14 had femoropopliteal bypasses, and 11 had femorodistal bypasses with an overall perioperative mortality of 3/25 (12%). Mortality at 6 months was high (33%) and was similar in both the grafted and amputation groups. Patients having reconstruction fared well in terms of independent mobility, use of long-term care, and length of hospital stay. Patients over 80 years of age with critical ischaemia should not be denied the opportunity of vascular reconstruction.     

The metabolic cost of lower extremity amputation

Amputation surgery should be approached as the first step in the rehabilitation of a patient with a non-functioning, salvageable limb. Before performing amputation surgery, the rehabilitation team should have an understanding of outcome expectations for the individual patient. Biologic joints are energy couples. When performing amputation surgery, more proximal amputations, accompanied by the removal of more joints, decreases the ability of patients to walk and live independently. Functional outcome appears to increase with the length of the residual limb.     

Fatal hand sepsis in Tanzanian diabetic patients

Hand infections are common presentations among diabetic patients admitted to hospital in Tanzania. The morbidity and mortality are high and patients' hospital inpatient stay tend to be prolonged because of suboptimal therapy. We describe four diabetic patients with hand infections and fatal outcomes. In contrast to patients with foot infections, none of our patients had clinical evidence of peripheral neuropathy or vascular disease. All four patients eventually died in hospital after acquiring hand sepsis and diabetic ketoacidosis which did not respond to prolonged courses of intravenous insulin and antimicrobials. Literature review suggests such infections are at least as likely to include Gram-negative organisms as Staphylococcus aureus. Primary management should have included aggressive surgery with limb amputation if necessary with adjunctive antimicrobial therapy.     

Patient recovery after infrainguinal bypass grafting for limb salvage

PURPOSE: The outcome of infrainguinal bypass surgery for limb salvage has traditionally been assessed by graft patency rates, limb salvage rates, and patient survival rates. Recently, functional outcome of limb salvage surgery has been assessed by patient ambulatory status and independent living status. These assessments fail to consider the adverse long-term patient effects of delayed wound healing, episodes of recurrent ischemia, and need for repeat operations. An ideal result of infrainguinal bypass surgery for limb salvage includes an uncomplicated operation, elimination of ischemia, prompt wound healing, and rapid return to premorbid functional status without recurrence or repeat surgery. The present study was performed to determine how often this ideal result is actually achieved. METHODS: The records of 112 consecutive patients who underwent initial infrainguinal bypass surgery for limb salvage 5 to 7 years before the study were reviewed for operative complications, graft patency, limb salvage, survival, patient functional status, time to achieve wound healing, need for repeat operations, and recurrence of ischemia. RESULTS: The mean patient age was 66 years. The mean postoperative follow-up was 42 months (range, 0 to 100.1 months). After operation 99 patients (88%) lived independently at home and 103 (92%) were ambulatory. There were seven perioperative deaths (6.3%), and wound complications occurred in 27 patients (24%). By life table, the assisted primary graft patency and limb salvage rates of the index extremity 5 years after operation were 77% and 87%, respectively, and the patient survival rate was 49%. At last follow-up or death, 73% of the patients (72 of 99) who lived independently at home before the operation were still living independently at home, and 70% (72 of 103) of those who were ambulatory before the operation remained ambulatory. Wound (operative and ischemic) healing required a mean of 4.2 months (range, 0.4 to 48 months), and 25 patients (22%) had not achieved complete wound healing at the time of last follow-up or death. Repeat operations to maintain graft patency, treat wound complications, or treat recurrent or contralateral ischemia were required in 61 patients (54%; mean, 1.6 reoperations/patient), and 26 patients (23.2%) ultimately required major limb amputation of the index or contralateral extremity. Only 16 of 112 patients (14.3%) achieved the ideal surgical result of an uncomplicated operation with long-term symptom relief, maintenance of functional status, and no recurrence or repeat operations. CONCLUSIONS: Most patients who undergo infrainguinal bypass surgery for limb salvage require ongoing treatment and have persistent or recurrent symptoms until their death. A significant minority have major tissue loss despite successful initial surgery. Clinically important palliation is frequently achieved by bypass surgery, but ideal results are distinctly infrequent.     

Usefulness of transcutaneous oximetry in vascular surgery

The assessment is presented of the value of transcutaneous oximetry in vascular surgery and in choosing the level of ischaemic limb amputation. Transcutaneous measurements of oxygen pressure (tcp02) were performed in 172 patients operated on for chronic ischaemia of the lower limbs before and three weeks after the operation. The studied subjects had the following operations done: bifurcated or unilateral aortofemoral bypass, femoropopliteal bypass, restoration of patency of the iliac and femoral arteries, lumbar sympathectomy, lower limb amputation. The studies were carried out using Hellige SM 361 oxymonitor and a similar Polish device. For oximetric measurements superficial skin sensor (Clark's polarographic electrode) was used, which was applied into the dorsum of the foot and medial crural surface. Transcutaneous oximetry seems to be a useful method for the assessment of the results of operations restoring blood flow in lower limb arteries. It makes possible to evaluate the results of lumbar sympathectomy. Transcutaneous measurements of oxygen pressure are also a useful method for the assessment of results of amputation of chronically ischaemic lower limb.     

Femorotibial bypass in the elderly for revascularization of the severely ischemic lower extremity

In the elderly, revascularization of a severely ischemic lower extremity with occlusion of both femoral and popliteal arteries often can be achieved by surgical construction of a distal bypass to the tibial or peroneal arteries. An aggressive diagnostic and therapeutic approach is necessary, in an attempt to prevent recourse to primary amputation. Femoroperoneal or femorotibial bypass can be performed safely and is recommended in elderly patients with advanced ischemia of a lower extremity with absolute indications for surgical intervention, e.g., gangrene, gangrenous ulceration or rest pain. A significant number of limbs can be salvaged by this method. Although the mortality rate in the older age groups is predictably higher, the overall rate for this operation compares favorably with that for primary amputation.     

Suppression by coffee cherry of the growth of spontaneous mammary tumours in SHN mice

Acute arterial occlusion in the lower extremities of patients with gynecologic cancers may not be immediately recognized in the postoperative period, despite the known risk of hypercoagulability associated with malignancy. Such delays in recognition and treatment can result in irreversible but potentially preventable tissue injury. This report describes three cases of acute arterial occlusion of the femoral and/or external iliac arteries in the immediate postoperative period following radical pelvic surgery. Two patients lost the involved limb due to irreversible changes resulting from prolonged ischemia. One patient was diagnosed while the involved limb was still viable and surgical revascularization was successfully performed. These cases illustrate the potential morbidity in unrecognized acute limb ischemia and the case with which it may be overlooked. Systematic documentation of arterial patency is recommended in the postoperative period, noting peripheral pulses and patient complaints related to the lower extremities. Rapid diagnosis and surgical intervention significantly increase the chance of maintaining viability of the involved limb.     

Transmetatarsal amputation

We have reviewed the records of 25 patients who underwent a transmetatarsal amputation at San Francisco General Hospital. The average patient age was 63 years old. Twelve of the patients were diabetic, while transmetatarsal amputations were performed in eleven with simple arteriosclerosis. Two patients underwent amputations for either trauma or nonhealing ulcer. Thirteen of the patients healed their amputation, and twelve of these became ambulatory. Eleven required higher amputation, because of nonhealing due to infection in seven and progressive ischemia in four. One patient died on the first postoperative day of pneumonia. The failure group was younger, contained more diabetics, and had a higher incidence of infection. The operative procedure of transmetatarsal amputation is described. We believe that patients with distal gangrene without spreading infection should be considered for transmetatarsal amputation, reserving initial below-knee amputation for those with greater involvement of the foot.     

Rotationplasty

Today rotationplasty is well established as an acceptable procedure for limb salvage in patients who have a malignant tumor in the femur or tibia. The main indication is that it is the alternative to amputation. Rotationplasty should further be used in the very young child because of growth-dependent complications that can be expected after tumor resection and any kind of reconstruction. This article covers the classification of the different types of rotationplasties, the operative procedure, prosthetic care, and the functional results.     

Surgical aspects in arterial occlusion (author's transl)

Acute arterial occlusion was found to be the most frequent emergency (10%) among vascular patients of the Department of Surgery of the University of Düsseldorf. Rheumatic heart diseases receded as etiological factors whereas atherosklerotic obstructive diseases exhibited a clear increasing tendency. Operation is urgent if acute ischemia is present. The best method is represented by embolectomy by means of the Fogarty-catheter, if it is performed within the first 6 to 12 hours after or vascular occlusion. Angiography is only indicated if ischemia is not complete or if the cartoid artery or great visceral arteries are involved. In cases of incomplete occlusion embolectomy may be successful even after days and weeks. Mortality after these operations is found to be 18 to 20%, the rate of amputation being 9%. The final results of operative results are better in arterial embolism than in arterial thrombosis.     

Absorption and distribution studies on chlorinated oleic acid and extracts of chlorinated lipid and protein fractions of flour in rats

Fourty-five reconstructions of the profunda femoris artery were performed in 41 patients during the period from 1972 to 1974. 78% were operated upon for pain at rest or distal gangrene. Three patients died postoperatively and in 5 cases the reconstruction failed to save the limb. In 1 additional case the operation probably lowered the amputation level to below knee. There was only 1 late occlusion. In the present material profundaplasty alone or combined with iliac reconstruction could relieve rest pain and save limbs when no other possibilities except amputation existed. However, when significant obstruction of the profounda femoris artery is demonsrated by angiography, profundaplasty should probably be perferred to femoro-popliteal reconstruction in most cases since it represents a minor operation with encouraging long-term results. Lateral angiograms of the deep femoral artery should supplement conventional angiography or lower limb atherosclerosis.     

Value of continued efforts at limb salvage despite multiple graft failures

Treatment of patients with limb-threatening ischemia after multiple failed bypasses remains difficult and controversial. Further revascularization procedures despite failure of the original procedure may be viewed as futile. The purpose of this report is to determine the efficacy of third or fourth revascularization procedures after the original and second procedures fail. Over a 10-year period from January 1, 1983, to December 31, 1992, 312 infrainguinal bypasses were performed on 271 consecutive patients for foot salvage. The overall limb salvage rate was 84%, and the operative mortality rate was 3.7% (10 patients). Sixteen patients (5.8%) had repeat infrainguinal bypasses performed after failure of two or more prior bypass procedures in the same leg. Twenty-three reconstructions were performed in these 16 patients. There were no operative deaths. One half of these patients had major amputations performed within the first year following their tertiary or fourth reconstructive procedure. Sixty-two percent of patients have survived longer than 3 years after their third or fourth procedure. One half of these patients have maintained graft patency and an excellent quality of life. Only 22% of the patients requiring amputation ambulated with a prosthesis, whereas all revascularized patients ambulated. Although this subset of patients is known to have an increased risk of repeated graft failure and limb loss, we believe continued efforts at limb salvage despite multiple previous graft failures is justified.     

The total contact cast: a method for treating neuropathic diabetic ulcers

Plantar ulcers that do not heal in patients with diabetes and peripheral sensory neuropathy have been shown to be precursors of lower extremity amputation. The total contact cast is considered by many authorities to be the most effective technique for healing of wounds in the neuropathic extremity, yet it still is not widely used in clinical practice. Use of the total contact cast allows mobilization and results in diminished edema and decreased pressure over the ulcerated area. Complete healing usually occurs in eight weeks or less. Total contact casting with careful follow-up should be considered as a useful modality for healing plantar ulcers in diabetic patients with neuropathy of the extremities.     

Is it possible to predict limb viability in complex Gustilo IIIB and IIIC tibial fractures? A comparison of two predictive indices

The patient with severe lower limb trauma presents a management dilemma; whether to amputate primarily or to attempt limb salvage. In recent years, many predictive indices have been published which purport to identify limbs which are non-viable. We retrospectively applied two recently described indices, the Mangled Extremity Severity Score (MESS) and the Limb Salvage Index (LSI), to 54 limbs in 50 patients with either Gustilo IIIB or IIIC complex tibial fractures. There were 22 amputations (40.7 per cent) in the series. The mean MESS score in the limb salvage group was 3.8 (range 2-10), and the mean MESS score in the amputation group was 7.7 (range 4-13) (P < 0.0001). The mean LSI score in the limb salvage group was 3.6 (range 3-8), and the mean LSI score in the amputation group was 6.9 (P < 0.01). However, in the group with MESS scores > 7 (which recommends amputation), there were three limbs which were salvaged with acceptable functional outcome. Similarly, in those with LSI scores > 6 (which recommends amputation), there were seven limbs successfully salvaged. A MESS > 7 offered a greater relative risk of amputation (9.2) than a LSI score > 6 (5.3). We found both indices of use in predicting limb salvage and functional outcome. However, neither is sufficiently accurate to be considered absolutely reliable in clinical practice.